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FQHCs and RHCs T1015 Claims Processing Notice Revision

Date: 10/16/24

UPDATED Notice for FQHCs & RHCs Regarding T1015 Claims Processing

Medical Record Review When Multiple T1015 Visits Billed for Same Member on the Same Day

AHCCCS defines a FQHC/RHC visit as a face-to-face encounter with a licensed AHCCCS-registered practitioner during which an AHCCCS-covered ambulatory service is provided when that service is not incident to another service. Multiple encounters with more than one practitioner within the same discipline, i.e., dental, physical, behavioral health, or with the same practitioner and which take place on the same day and at a single location, constitute a single visit unless the patient, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. In this circumstance, the subsequent encounter is considered a separate visit.

Effective 9/01/2024, Arizona Complete Health-Complete Care Plan (AzCH-CCP) and Care1st Health Plan Arizona (Care1st) implemented a pre-payment medical record review process for multiple T1015 visits billed for the same member on same day, within the same discipline, and at a single location to determine if the subsequent T1015 visit qualifies as a separately payable visit.   

What to expect:

  1. Select claims billed with more than one T1015 visit for the same member on the same day, within the same discipline, and at the same location are identified for medical records review.
  2. The claim’s remittance advice includes reason code EXU1 “CLAIM CANNOT BE PROCESSED WITHOUT MEDICAL RECORDS.”
  3. To ensure comprehensive review, please submit medical records for all T1015 visits and services billed for the same member on the same day as the T1015 visit identified for medical records review.
  4. You may submit medical records through our provider portal, mail, or via clearing house.
  5. Upon receipt and review of the medical records,
    • If review determines the subsequent T1015 visit is in accordance with AHCCCS policy, the claim is processed as billed.
    • If review determines the subsequent T1015 visit is not in accordance with AHCCCC policy, the claim is reprocessed with reason code EXb2 “MEDICAL RECORDS SUBMITTED DO NOT SUPPORT THE SERVICE BILLED” and the visit is not reimbursed.

If you disagree with the determination made following medical record review, refer to our provider manual (available on our website) for details on how to file a reconsideration or claim dispute. You may also visit the Medicaid Provider Claim Dispute page on our website.

As a reminder, as per AHCCCS policy, a service which is provided incident to another service, whether or not on the same day or at the same location, is considered to be part of the visit and is not reimbursed separately.

Resources

If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.